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pplications Will Be ProcesJQ*hen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE U . _ 2 �98Q APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) P * '1 <br /> s D'7 1 apS oM`� WELL <br /> JJVN -JO�;Q1J!N LOCAPENVIRONMENTAL HEALTH PERMIT <br /> LTH. DISTRICT - WATER QUALITY ��/ �0�h�{' CI <br />" (COMPLETE IN TRIPLI rc.�g "J <br /> Application isherebymadetvthe an Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> k made in com ire wiS�ylaaqui ouyOrdin No. 18�2�and lei�p�Legulations of the San a �. ocal th Qistrict. <br /> I :� bRA <br /> 7�cs City/Town 7� ) <br /> Exact Site A ress } �^/ <br /> Phone <br /> Owner's Nam <br /> Address �-J f! �Z_j ��P_4 v City T-b a <br /> Contractor's Name L y License Business Ph o e <br /> Contractor's Address y J Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q-_ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ; <br /> REPLACEMENT❑ F - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ~ <br /> — _ Sewage Disposal Field -. .- Cesspool/Seepage Pit - - Other <br /> k Property Line Private Domestic Well Public Domestic Well �- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 91Z7 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 13 State Work Don ` <br /> PUMP REPAIR: tate Work Do <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �- <br /> I` Describe Material and Procedure " <br /> f 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the.San Joaquin Local Health District. �. <br /> k <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor' or sub-contracting signature certifies the following:" c ify that in the performance of the work forwhich this <br /> per . s i ed, I hall a plo persons subject to workman's com ns ton laws of California." <br /> I ill out Ins ecti prior to grouting and a final inspe on. <br /> Signed X -- -Till -- — Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR IJEPARTM NT USE ONLY <br /> PHASE I 00F (� <br /> f Application Accepted By Date <br /> F Additional Comments: <br /> r4 Phase II Grout Inspection hase III F' al Inspection <br /> x Inspection By Date Inspection By Date <br /> 4 <br /> . Fee Is Due: El ANNUALLY ❑ PER UNIT PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I "BILLING REMITTANCE $- AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> G/ AMOUNT <br /> FEE / <br /> LESS <br /> PRORATION - <br /> k PLUSy- <br /> PENALTY <br /> P <br /> l OTHER <br /> OTHER A <br /> t Received by Date °t'c>.� "� Receipt No. - Permit No. Issuance Date - Mahed Delivered <br /> k _ <br /> k APPLICANT—RETURN-ALL COPIES TOi ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E:HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 ' <br />